National Surgical Infection Prevention Project Research Articles

What are the patterns of prophylactic postoperative oral antibiotic use after foot and ankle surgery?

The CDC estimates 23% of healthcare-associated infections to be surgical site infections, with alarming prevalence of antibiotic-resistant organisms. While there is consensus regarding preoperative prophylaxis, orthopaedic surgeons' use of prophylactic postoperative oral antibiotics is less defined. We investigated surgeons' use of prophylactic postoperative oral antibiotics after elective outpatient foot or ankle procedures, identifying (1) frequency of use, (2) regimen preferences, (3) personal indications, and (4) associated experience and demographics. Using a cross-sectional survey design, a questionnaire was emailed to all active and candidate members of the American Orthopaedic Foot and Ankle Society. Supplementary questions captured demographic information. We invited 1136 members to participate; 22 addresses produced delivery failure messages, leaving 1114 members as potential participants. After nonresponses and exclusions, 312 (28%) responses were analyzed. Statistical analysis used Pearson's chi-square test, Fisher's exact test, and multivariate regression. The majority (75%) of respondents reported use of prophylactic postoperative oral antibiotics. Most users (69%) prescribed to fewer than 25% of patients, although 16% prescribed for all elective cases. The most frequent regimen was cephalexin 500 mg four times a day (63%) and the most common duration was 5 to 7 days (50%). Surgeons' most common indications were previous infection (71%), medical comorbidities (65%), and previous wound-healing difficulties (56%). Those who do and do not prescribe prophylactic postoperative oral antibiotics showed no difference in surgical site infection rate or any demographic category. Surgeons' reported use of prophylactic postoperative oral antibiotics after elective foot or ankle surgery was common, without demographic association. Commonalities were identified in antibiotic regimen and personal indications for this practice. Comparative clinical studies are warranted to elucidate the efficacy of prophylactic postoperative oral antibiotics and establish evidence-based guidelines for their use.

Use and Outcomes of Extended Antibiotic Prophylaxis in Urological Cancer Surgery

Although perioperative antibiotic prophylaxis prevents postoperative infectious complications, national guidelines recommend cessation of antibiotics within 24 hours after the procedure. Extended antibiotic prophylaxis beyond 24 hours may contribute to hospital acquired infections such as Clostridium difficile colitis. We evaluated practice patterns of antibiotic prophylaxis in genitourinary cancer surgery and assessed the impact of antibiotic prophylaxis on hospital acquired C. difficile infections. We identified 59,184 patients treated with radical prostatectomy, 27,921 who underwent partial or radical nephrectomy, and 5,425 treated with radical cystectomy for prostate, kidney and bladder cancers, respectively, from the Premier Perspective Database (Premier Inc., Charlotte, North Carolina) from 2007 to 2012. We constructed hierarchical linear regression models to identify patient and hospital factors associated with extended antibiotic prophylaxis. We evaluated the association between extended antibiotic prophylaxis and C. difficile infections for patients who underwent partial or radical nephrectomy and radical cystectomy with multivariate logistic regression. Surgery specific models demonstrated that hospital identity was associated with a substantial proportion of the variation in extended antibiotic prophylaxis (20% to 35% for radical prostatectomy, partial or radical nephrectomy, and radical cystectomy). Postoperative C. difficile colitis occurred in 0.02% of patients treated with radical prostatectomy, 0.23% of those treated with partial or radical nephrectomy and 1.7% of those treated with radical cystectomy. On multivariate analysis extended antibiotic prophylaxis was associated with higher odds of C. difficile infection after partial or radical nephrectomy (OR 3.79, 95% CI 2.46-5.84) and radical cystectomy (OR 1.64, 95% CI 1.12-2.39). Antibiotics may be overused after genitourinary cancer surgery and this overuse is associated with hospital acquired C. difficile colitis. Efforts are needed to encourage greater compliance with evidence-based approaches to postoperative care.

Evaluating clinical indications for continued catheterisation

Evaluating clinical indications for continued catheterisation

Adherence to Surgical Site Infection Guidelines in Cardiac Surgery in a Tertiary Hospital in Dubai, United Arab Emirates

Purpose: To assess the appropriateness and compliance of antibiotic prophylaxis practices in cardiac surgery in a tertiary hospital in United Arab Emirates (UAE) using three international guidelines. Methods: A retrospective study was performed by reviewing patients’ files admitted for cardiac surgery between January 2008 and February 2010. The study evaluated the adherence of health care professionals to three international guidelines with regard to antibiotic prophylaxis. The guidelines were National Surgical Infection Prevention Project (NSIPP), Society of Thoracic Surgeons (STS) and American College of Cardiology/American Heart Association (ACC/AHA). Patients’ records were reviewed for antibiotics used for prophylaxis, frequency of administration, timing and number of doses. Results: A total of 92 patients were included in the study. Based on the international guidelines, only 89.1 and 79.3% of the patients received the recommended pre- and post-operative antibiotics, respectively. On the other hand, 93.5% of the patients received the right antibiotic dose while the total duration of all antimicrobial agents used for prophylaxis was concordant with the guidelines (48 h) in only 67.4% of the patients.Conclusion: Adherence to international antimicrobial prophylaxis guidelines for cardiac surgery was found to be suboptimal in the study hospital in Dubai. Various interventions are needed via developing local evidence-based protocols in collaboration with surgeons, and also to strengthen regulations for ensuring adherence to these guidelines.Keywords: Antimicrobial prophylaxis, International guidelines, Cardiac surgery

Quality of Surgical Care in Liver and Small-Bowel Transplant: Approach to Risk Assessment and Antibiotic Prophylaxis

In August 2002, The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented the National Surgical Infection Prevention project. The goal of the project was to decrease the morbidity and mortality associated with postoperative surgical site infections through appropriate selection and timing of administration and discontinuation of prophylactic antimicrobials. The National Surgical Infection Prevention project, however, excluded transplant surgeries from its focus because of the lack of randomized clinical trials comparing antimicrobial agents. The goals of this article are to (1) provide a framework for risk factors associated with surgical site infections in liver, small-bowel, and multivisceral transplants; (2) review general principles of the appropriate antimicrobial prophylaxis; (3) provide a framework for developing a triage of liver, small-bowel, and multivisceral transplant candidates for appropriate antibiotic prophylaxis; and (4) develop an approach to further quality improvements in transplant surgical care. A multidisciplinary team produced recommendations for antibacterial prophylaxis and monitoring.

Quality of surgical care in liver and small-bowel transplant: approach to risk assessment and antibiotic prophylaxis

In August 2002, The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented the National Surgical Infection Prevention project. The goal of the project was to decrease the morbidity and mortality associated with postoperative surgical site infections through appropriate selection and timing of administration and discontinuation of prophylactic antimicrobials. The National Surgical Infection Prevention project, however, excluded transplant surgeries from its focus because of the lack of randomized clinical trials comparing antimicrobial agents. The goals of this article are to (1) provide a framework for risk factors associated with surgical site infections in liver, small-bowel, and multivisceral transplants; (2) review general principles of the appropriate antimicrobial prophylaxis; (3) provide a framework for developing a triage of liver, small-bowel, and multivisceral transplant candidates for appropriate antibiotic prophylaxis; and (4) develop an approach to further quality improvements in transplant surgical care. A multidisciplinary team produced recommendations for antibacterial prophylaxis and monitoring.

Indwelling Urinary Catheter Use in the Postoperative Period: Analysis of the National Surgical Infection Prevention Project Data

Indwelling Urinary Catheter Use in the Postoperative Period: Analysis of the National Surgical Infection Prevention Project Data

Regarding the risk for development of surgical site infections and bacterial prophylaxis in liver transplantation

Regarding the risk for development of surgical site infections and bacterial prophylaxis in liver transplantation

Multidisciplinary approach to optimizing antibiotic prophylaxis of surgical-site infections

Surgical-site infections (SSIs) are a common cause of nosocomial infections. More than 2% of surgical patients in the United States will develop an SSI, with at least 50% of those patients more likely to spend time in an intensive care unit.1 The efficacy of antimicrobial prophylaxis in reducing the incidence of SSIs has been well established for many surgical procedures. However, antimicrobial use must be weighed against the risks of use, which include the potential for adverse drug reactions, emergence of bacterial resistance, and cost. Several organizations, including the American Society of Health-System Pharmacists, have published guidelines2 that outline the choices of antimicrobial agents and the timing and number of doses for specific surgical procedures. Even with guidelines for antimicrobial prophylaxis, several studies have demonstrated that the potential still exists for improving the care of surgical patients. In 2002, the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention implemented the National Surgical Infection Prevention Project. Through this collaboration and the review of the available evidence, experts in infection control, epidemiology, and surgical-infection prevention (the Surgical Infection Prevention Guideline Writers Workgroup) three core measures for surveillance and quality improvement were recommended.1 The three measures are (1) initiating prophylactic antimicrobials within 1 hour of surgical incision (2 hours for vancomycin), (2) choosing antimicrobials according to published guidelines, and (3) discontinuing antimicrobial prophylaxis within 24 hours after surgery. The focus on timing and selection was on the basis of the potential of these measures to reduce SSIs. The limit on duration was chosen as a measure to help prevent unnecessary antimicrobial resistance.

Prophylactic Antibiotic Compliance with Published Guidelines

Purpose: To examine the rate of compliance with National Surgical Infection Prevention Project performance measures and compliance with American Society of Health-System Pharmacists guidelines for procedures not covered by these measures and to evaluate noncompliance for explanatory factors. Methods: A retrospective review of all patients receiving prophylactic antibiotics for Class I (clean) or Class II (clean-contaminated) surgical procedures. Information collected included antibiotic ordered, antibiotic given, dose of antibiotic, time of administration, time of incision, time of closure, duration of procedure, need for re-dosing during the procedure, documentation of re-dosing administered, and antibiotic discontinuation. Results: Choice of antibiotic for prophylaxis was appropriate in 99% of the 568 procedures. Antibiotic was administered too early in 94 of 527 (17.8%) patients. Prophylactic antibiotics were inappropriately continued for more than 24 hours in 43 of 216 (20%) patients undergoing noncardiothoracic procedures and for more than 48 hours in 4 of 10 (40%) in patients undergoing cardiothoracic surgery. Conclusion: Although improvements in key performance measures related to prophylactic antibiotic agent selection, timing of administration, and discontinuation have been made compared to data collected in a larger multicenter study conducted at the beginning of this century, there remains considerable room for improvement.

SURGICAL ANTIBIOTIC PROPHYLAXIS IN SMALLER HOSPITALS

In 2004, The Victorian Hospital Acquired Infection Surveillance System Coordinating Centre established a smaller hospital (<100 beds) surveillance programme that included an optional 'surgical antibiotic prophylaxis' (SAP) module. Appropriate SAP is believed to be one of the most effective strategies to reduce surgical site infections after certain surgical procedures. Trained infection control nurses in the participating hospitals were asked to collect SAP data for the first 50 consecutive procedures that could be classified into 1 of 12 surgical groups. The choice, timing and duration of antibiotics were compared against the Australian Therapeutic Antibiotic version 12 Guidelines and the US National Surgical Infection Prevention Project Advisory Statement. Fifty-one of the 87 smaller hospitals that participated in the surveillance programme of The Victorian Hospital Acquired Infection Surveillance System Coordinating Centre carried out surgery. Over 20 months, 25 of these hospitals contributed data on 1872 procedures. Antibiotic choice, timing and duration were 52.6, 54.7 and 76.1%, respectively, concordant with published recommendations. For antibiotic choice in five surgical groups (appendectomy, colon surgery, gastric surgery and abdominal and vaginal hysterectomies), less than half of the procedures were concordant with the Australian Therapeutic Antibiotic Guidelines. Substantial opportunities exist in smaller hospitals to improve compliance with published SAP recommendations. Further studies are required to determine the reasons for poor compliance with these recommendations.

Antimicrobial Prophylaxis for Surgery: An Advisory Statement From the National Surgical Infection Prevention Project

Antimicrobial Prophylaxis for Surgery: An Advisory Statement From the National Surgical Infection Prevention Project

Antimicrobial prophylaxis for surgery: An advisory statement from the National Surgical Infection Prevention Project

In January 2003, leadership of the Medicare National Surgical Infection Prevention Project hosted the Surgical Infection Prevention Guideline Writers Workgroup meeting. The objectives were to review areas of agreement among the published guidelines for surgical antimicrobial prophylaxis, to address inconsistencies, and to discuss issues not currently addressed. The participants included authors from most of the published North American guidelines for antimicrobial prophylaxis and several specialty colleges. The workgroup reviewed currently published guidelines for antimicrobial prophylaxis. Nominal group process was used to draft a consensus paper that was widely circulated for comment. The consensus positions of the workgroup include that infusion of the first antimicrobial dose should begin within 60 minutes before surgical incision and that prophylactic antimicrobial agents should be discontinued within 24 hours of the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis including specific suggestions regarding antimicrobial selection.

CMS and CDC Launch National Surgical Infection Prevention Project

CMS and CDC Launch National Surgical Infection Prevention Project